LIS

Virginia Law

Administrative Code

Creating a Report: Check the sections you'd like to appear in the report, then use the "Create Report" button at the bottom of the page to generate your report. Once the report is generated you'll then have the option to download it as a pdf, print or email the report.

Virginia Administrative Code
Title 12. Health
Agency 30. Department of Medical Assistance Services
Chapter 141. Family Access to Medical Insurance Security Plan
11/21/2024

12VAC30-141-720. Request for appeal.

A. Requests for internal appeal of MCO adverse benefit determinations shall be submitted orally or in writing to the MCO. Unless the enrollee requests an expedited appeal, an oral appeal request must be followed by a written appeal request. The enrollee must exhaust the MCO's internal appeals process before appealing to DMAS.

B. If the MCO fails to adhere to the notice or timing requirements set forth in this part, the enrollee is deemed to have exhausted the MCO's internal appeals process and may initiate a state fair hearing.

C. Requests for appeal of adverse actions made by the LDSS, CPU, or DMAS, or of internal appeal decisions by the MCO shall be submitted to DMAS.

D. Any communication expressing a desire to have an adverse benefit determination by an MCO reviewed shall be treated as a request for an internal appeal. Any communication expressing a desire to have an adverse action by the LDSS, CPU, or DMAS reviewed shall be treated as a request for a state fair hearing. Any communication expressing a desire to have an MCO internal appeal decision reviewed shall be treated as a request for a state fair hearing.

E. To be timely, requests for an internal appeal of an MCO's adverse benefit determination shall be received by the MCO no later than 60 calendar days from the date of the MCO's notice of adverse benefit determination.

F. To be timely, requests for an appeal of an adverse benefit determination upheld in whole or in part by the MCO's internal appeal decision shall be received by DMAS within 120 calendar days from the date of the internal appeal decision.

G. To be timely, requests for appeal of a local department of social services, DMAS, or CPU adverse action shall be filed with DMAS no later than 30 calendar days from the date of the notice of adverse action. Requests for appeal of an agency determination shall be considered filed with DMAS on the date the request is postmarked if mailed, or on the date the request is received if delivered other than by mail, by DMAS.

Statutory Authority

§ 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Historical Notes

Derived from Virginia Register Volume 23, Issue 7, eff. January 10, 2007; amended, Virginia Register Volume 25, Issue 14, eff. April 15, 2009; Virginia Register Volume 35, Issue 20, eff. June 26, 2019.

Website addresses provided in the Virginia Administrative Code to documents incorporated by reference are for the reader's convenience only, may not necessarily be active or current, and should not be relied upon. To ensure the information incorporated by reference is accurate, the reader is encouraged to use the source document described in the regulation.

As a service to the public, the Virginia Administrative Code is provided online by the Virginia General Assembly. We are unable to answer legal questions or respond to requests for legal advice, including application of law to specific fact. To understand and protect your legal rights, you should consult an attorney.